Role of neutrophil-lymphocyte ratio as a potential marker to differentiate between pulmonary tuberculosis and community-acquired pneumonia in children


  • Taskina Mosleh Department of Paediatrics, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh
  • Nitin Das Department of Paediatrics, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh
  • Mahbub Mutanabbi Department of Paediatrics, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh



NLR, Lymphocyte, Neutrophil, Pneumonia, TB


Background: This is often creating challenge to differentiate pulmonary tuberculosis (TB) with community acquired pneumonia (CAP) particularly in children. The neutrophil-lymphocyte count ratio (NLR) as an indicator of inflammation has been used in various infectious diseases. The aim of this study was to investigate the role of NLR as a possible marker in differentiating pulmonary TB from CAP.

Methods: In this retrospective record based analytic study, conducted from July 2020 to Dec 2021, patient aged 2 months to 18 years diagnosed as pulmonary TB or CAP were enrolled in this study i.e., 155 children after exclusion. The diagnostic ability of NLR in differentiating between pulmonary Tb and CAP were assessed.

Results: Out of 155 children, 85 (54.8%) had CAP and 70 (45.1%) had pulmonary TB. Mean values of NLR were significantly lower in patients with TB than in pneumonia (3.16±1.9 vs 5.05±1.2, p<0.000). Total WBC, neutrophil, Hb and CRP were also significantly lower in patients with pulmonary TB. On the other hand, lymphocyte count was significantly higher in children with pulmonary TB in compare to children with pneumonia (p=0.04).

Conclusions: The NLR can be used as a useful simple laboratory marker in differentiating children with Pulmonary TB from CAP, especially in resource limited high TB disease burden countries.

Author Biography

Taskina Mosleh, Department of Paediatrics, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh

Assistant Professor, Department of Pediatrics,Bangabandhu Sheikh Mujib Medical University(BSMMU)


Global tuberculosis report 2021. Geneva: World Health Organization; 2021. Available at: Accessed on 9 September 2022.

Global tuberculosis report 2020. Geneva: World Health Organization; 2020. Available at: Accessed on 9 September 2022.

Chan CH, Cohen M, Pang J. A prospective study of community-acquired pneumonia in Hong Kong. Chest. 1992;101(2):442-6.

Liam CK, Pang YK, Poosparajah S. Pulmonary tuberculosis presenting as community-acquired pneumonia. Respirology. 2006;11(6):786-92.

Siddiqi K, Lambert ML, Walley J. Clinical diagnosis of smear-negative pulmonary tuberculosis in low-income countries: the current evidence. Lancet Infect Dis. 2003;3(5):288-96.

Kang YA, Kwon SY, Yoon HI, Lee JH, Lee CT. Role of C-reactive protein and procalcitonin in differentiation of tuberculosis from bacterial community acquired pneumonia. Korean J Intern Med. 2009;24:337-42.

Ugajin M, Miwa S, Shirai M, Ohba H, Eifuku T, Nakamura H. Usefulness of serum procalcitonin level in pulmonary tuberculosis. Eur Respir J. 2011;37:371-5.

Tintinger GR, Van der Merwe JJ, Fickl H, Rheeder P, Feldman C, Anderson R. Soluble triggering receptor expressed on myeloid cells in sputum of patients with community- acquired pneumonia or pulmonary tuberculosis: a pilot study. Eur J Clin Microbiol Infect Dis. 2012;31:73-6.

Yoon NB, Son C, Um SJ. Role of the neutrophil-lymphocyte count ratio in the differential diagnosis between pulmonary tuberculosis and bacterial community-acquired pneumonia. Ann Lab Med. 2013;33(2):105-10.

El-Emshaty W, Mashaly M, Moawad A. Diagnostic value of neutrophil-lymphocyte ratio versus C-reactive protein in discrimination between different pathogens causing community-acquired pneumonia. Comp Clin Pathol. 2017;26:757-65.

Sarraf KM, Belcher E, Raevsky E, Nicholson AG, Goldstraw P, Lim E. Neutrophil/lymphocyte ratio and its association with survival after complete resection in non-small cell lung cancer. J Thorac Cardiovasc Surg. 2009;137:425-8.

Cedrés S, Torrejon D, Martínez A, Martinez P, Navarro A, Zamora E et al. Neutrophil to lymphocyte ratio (NLR) as an indicator of poor prognosis in stage IV non-small cell lung cancer. Clin Transl Oncol 2012;14:864-9

Walsh SR, Cook EJ, Goulder F, Justin TA, Keeling NJ. Neutrophil lymphocyte ratio as a prognostic factor in colorectal cancer. J Surg Oncol. 2005;91:181-4.

Halazun KJ, Aldoori A, Malik HZ, Al-Mukhtar A, Prasad KR, Toogood GJ et al. Elevated preoperative neutrophil to lymphocyte ratio predicts survival following hepatic resection for colorectal liver metastases. Eur J Surg Oncol. 2008;34:55-60.

Tamhane UU, Aneja S, Montgomery D, Rogers EK, Eagle KA, Gurm HS. Association between admission neutrophil to lymphocyte ratio and outcomes in patients with acute coronary syndrome. Am J Cardiol. 2008;102:653-7.

Duffy BK, Gurm HS, Rajagopal V, Gupta R, Ellis SG, Bhatt DL. Usefulness of an elevated neutrophil to lymphocyte ratio in predicting long-term mortality after percutaneous coronary intervention. Am J Cardiol. 2006;97:993-6.

Ahsen A, Ulu MS, Yuksel S, Demir K, Uysal M, Erdogan M et al. As a new infl ammatory marker for familial Mediterranean fever: Neutrophil-to-lymphocyte ratio. Infl Ammation. 2013;36:1357-62.

Núñez J, Núñez E, Bodí V, Sanchis J, Miñana G, Mainar L et al. Usefulness of the neutrophil to lymphocyte ratio in predicting long-term mortality in ST segment elevation myocardial infarction. Am J Cardiol 2008;101:747-52.

Turkmen K, Erdur FM, Ozcicek F, Ozcicek A, Akbas EM, Ozbicer A et al. Platelet-to-lymphocyte ratio better predicts infl ammation than neutrophil-to-lymphocyte ratio in end-stage renal disease patients. Hemodial Int. 2013;17:391-6.

Lee JH, Song S, Soo-Young Y, Lim CS, Jae-Woo S, Hyon-Suk K. Neutrophil to lymphocyte ratio and platelet to lymphocyte ratio as diagnostic markers for pneumonia severity. Bri J Biomed Sci. 2016;73(3):140-2.

Abakay O, Abakay A, Sen HS, Tanrikulu AC. The relationship between inflammatory marker levels and pulmonary tuberculosis severity. Inflammation. 2015;38(2):691-6.

Lee H, Kim I, Kang BH, Um SJ. Prognostic value of serial neutrophil-to-lymphocyte ratio measurements in hospitalized community-acquired pneumonia. PLOS ONE. 2021;16(4):e0250067.

Hui KP, Chin NK, Chow K, Brownlee A, Yeo TC, Kumarasinghe G et al. Prospective study of the aetiology of adult community acquired bacterial pneumonia needing hospitalisation in Singapore. Singapore Med J. 1993;34:329-34.

Nyamande K, Lalloo UG, John M. TB presenting as community-acquired pneumonia in a setting of high TB incidence and high HIV prevalence. Int J Tuberc Lung Dis. 2007;11:1308e13.

Kunimoto D, Long R. Tuberculosis: still overlooked as a cause of community-acquired pneumoniaehow not to miss it. Respir Care Clin N Am. 2005;11:25e34.

De Jager CPC, Van Wijk PTL, Mathoera RB, De Jongh Leuvenink J, Can der Poll T, Wever PC. Lymphocytopenia and neutrophil-lymphocyte count ratio predict bacteremia better than conventional infection markers in an emergency care unit. Crit Care. 2010;14(5):R192.

Zahorec R. Ratio of neutrophil to lymphocyte counts-rapid and simple parameter of systemic inflammation and stress in critically ill. Bratisl Lek Listy. 2001;102(1):5-14.

Wyllie DH, Bowler IC, Peto TE. Relation between lymphopenia and bacteraemia in UK adults with medical emergencies. J Clin Pathol. 2004;57(9):950-55.

Goodman DA, Goodman CB, Monk JS. Use of the neutrophil: lymphocyte ratio in the diagnosis of appendicitis. Am Surg. 1995;61(3):257-9.

Kumar P, Sreenath RK, Raghavendra P, Maharaj, Ram S, Dhruvanandan K. Role of the Neutrophil-Lymphocyte Count Ratio in the Differential Diagnosis between Pulmonary Tuberculosis and Bacterial Community Acquired Pneumonia. JMSCR. 2020;8(3):345-9.

Veenstra H, Baumann R, Carroll NM. Changes in leucocyte and lymphocyte subsets during tuberculosis treatment; prominence of CD3dimCD56+ natural killer T cells in fast treatment responders. Clin Exp Immunol. 2006;145(2):252-60.

Park J, Lee H, Kim Y-K. Automated screening for tuberculosis by multiparametric analysis of data obtained during routine complete blood count. Int J Lab Hematol. 2014;36(2):156-64.

Wang J, Yin Y, Wang X. Ratio of monocytes to lymphocytes in peripheral blood in patients diagnosed with active tuberculosis. Braz J Infect Dis. 2015;19(2):125-31.

Naranbhai V, Kim S, Fletcher H. The association between the ratio of monocytes: lymphocytes at age 3 months and risk of tuberculosis (TB) in the first two years of life. BMC Med. 2014;12:120.

Jeon Y, Lee WI, Kang SY, Kim MH. Neutrophil-to-Monocyte-Plus-Lymphocyte Ratio as a Potential Marker for Discriminating Pulmonary Tuberculosis from Non tuberculosis Infectious Lung Diseases. Lab Med. 2019;16;50(3):286-91.






Original Research Articles